Exam 2 Flashcards by Aaron Fregoso

What is important for the nurse to avoid in suture removal?

allowing the external portion of a suture to go into the wound bed

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Regarding foam, what consideration should be taken in negative pressure wound therapy (wound vac)?

foam should not touch in-tact skin

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Describe serous fluid.

pale yellowy-clear.
Normal part of the wound healing process.

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Describe sanguineous drainage.

bright red bloody fluid from wound

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Describe serosanguineous wound drainage.

mixture of light yellowy and light red/pink fluid

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Describe purulent drainage.

thick, foul odor, sticky, milky, green/yellow, brown - indicates infection of the wound

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What type of drainage would likely be caused by wound trauma?

sanguineous

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What does REM stand for?

rapid eye movement

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What happens to gastric secretions during REM sleep?

increased gastric secretions

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Vivid dreams are an indication of what type of sleep?

REM

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In a medical facility, how can a nurse promote sleep?

provide healthy sleep environment (low lights, avoid sounds), try to do tasks all at once so you aren’t going in and out, and assess for any problems

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What are some things that may effect/disrupt sleep?

waking pts up for unnecessary treatment, exposure to computer/monitor light, poor environment, personnel frequently entering room

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What is the last resort for insomnia?

medication therapy

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What factors may promote insomnia?

poor sleep hygiene (video games/lights/stimulation before sleeping/lack of routine schedule), medical condition, shift work, and stress

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How is sleep apnea diagnosed?

sleep study

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What is a common symptom that occurs with sleep apnea?

excessive daytime sleepiness and snoring

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What is the primary treatment option for sleep apnea?

CPAP (continuous positive airway pressure)

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What is a primary concern for individuals who have narcolepsy?

safety

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What factors may increase occurrence of narcoleptic episodes, including cataplexy (sudden loss of muscle tone)?

strong emotion ( stress, anger, and fear)

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What may be the first sign of pneumonia, especially in older adults?

confusion

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Usage of what medical device may lead to HCAP (health care acquired pneumonia)?

ventilator

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What population is at increased risk for both CAP (community) and HCAP (healthcare)?

older adults

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What are some early symptoms of hypoxia?

restlessness, agitation, and anxious

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What are some late symptoms of hypoxia?

cyanosis, altered LOC

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Absent skeletal muscle tone may indicate which stage of sleep?

REM

What can be utilized to evaluate sleep?

STOP BANG Assessement

What happens to breathing with individuals who have sleep apnea?

air flow is blocked and breathing stops

What doe STOP BANG stand for?

S-snore? B-BMI T-tired? A- age O- observed? N- Neck size P- Pressure? G- gender

Give an example of individuals who are at an increased risk for insomnia.

those who do shift work

What type of dressing would likely be used to maintain/provide moisture to a wound?

hydrogel/hydrocolloid

What type of dressing would be effective to use on an excessively moist wound?

alginate or foam

Why is it important to ensure wound is not too dry?

if it is too dry, granulation (new tissue) will not thrive

What is primary concern after sharp debridement?

increased risk for infection, as tissue is now exposed

What may be effective to use on a wound to absorb drainage and reduce bacteria?

Aquacel Ag (silver)

What term describes the output from a stoma?

effluent

How should a stoma appear?

beefy red

Following ostomy procedures, how long is expected for stools to be liquid, regardless of the type?

up to 6 weeks

What refers to a surgical complication of ostomies in which effluent can leak into the abdominal cavity?

anastomotic leak

When is stomal necrosis most likely?

following surgery (3-5 days)

What may be required for patients who have had a resection of the terminal ileum?

B 12 replacement

What specific foods should be avoided for new ileostomy (pt education)?

celery, coconuts, corn popcorn, seeds, foods with peels, raw cabbage, meats with casings, and mushrooms

The nurse should emphasize the important of what mechanical action for a client who has a new ileostomy?

thoroughly chewing food, as this will prevent a clog within the lumen

What is expected of the initial output for an ileostomy?

viscous, green, shiny. High output (1500-1800cc daily)

After the adaptation phase, what is expected of the appearance of effluent from an ileostomy?

stool-colored brown, and toothpaste consistency

Due to the high acidity of ileostomy effluent, what concern should the nurse consider?

skin irritation

For the client who has a new ileostomy/existing ileostomy, what should the nurse educate them to never take?

laxative

What are the indications for colostomy irrigations?

improves quality of life by eliminating need for pouches, as well as providing bowel control

How long does colostomy irrigation take before it can be considered reliable?

approximately 6 weeks

What may cause candidiasis (yeast infection) of a stoma?

moisture, immunocompromised, and meds (chemo, antibiotics,)

What may cause retraction of a stoma?

surgical technique, weight gain, and thick abdominal wall

What should a nurse NEVER use within an ostomy pouch to eliminate odor?

aspirin

JP (Jackson-Pratt) drains are only effective when:

suction/negative pressure is activated

What is known as a normal breathing pattern?

eupnea

Kussmaul's (rapid and deep) respirations are expected in:

DKA (diabetic ketoacidosis)

What breathing pattern may occur in cardiac conditions (MI, heart failure)?

Cheyne-Stokes (cycles of apnea and hyperventilation)

What ways can a nurse promote respiratory function?

fluid intake, positioning, airway patency, pursed lip breathing, nebulizers, humidifiers

What type of clothing should those on O2 be encouraged to wear? Why?

cotton only, as it prevents fabric spark (O2 is very flammable)

What is the expected O2 saturation in those with COPD?

88-92%

What may oxygen greater than 24-32% (1-3L/min) do to COPD clients?

negate their stimulus to breathe, decreasing respiratory drive

Describe wound irrigation.

allow solution to flow from the least to most contaminated area

How should solutions be applied to the skin for wound cleaning?

using gentle friction

In what direction should a wound be cleaned?

from least contaminated area (in wound/incision/@drain) to the surrounding skin

Aquacel Ag is a great dressing type to prevent/reduce what?

infection

What is dehiscence?

partial or total separation of wound layers

What is an evisceration?

medical emergency by which the organs have protruded through a wound opening

What should increase in the diet of those with a wound?

protein

When should JP drains be emptied?

around half full

What describes the substances that come from a wound?

exudate

What type of surgically placed drain can hold up to 500 mL of drainage, compared to JP, which only holds 20-50 mL?

hemovac

Those who have viral pneumonia are at a higher risk for developing what?

bacterial pneumonia

What is important for clients who have pneumonia to increase? Why?

fluids, as it helps loosen secretions so phlegm can be excreted

What can a nurse use for those who have pneumonia to encourage deep breathing and coughing?

incentive spirometry

How can HAP be avoided by a facility?

placing conveniently located hand sanitizer dispensers and ensuring supplies for handwashing are maintained and available

How does a CPAP work?

the continuous air prevents airway from occluding, which maintains airway patency

What is the cure for narcolepsy?

there is no cure

What PPE is used for droplet precautions?

face shield, mask, gloves

What type of breathing is expected with hypoxia?

rapid, shallow breathing

What is known as collapse of an ostomy lumen? What may pts with this condition need?

stomal stenosis; laxatives

In regard to communication, what should be evaluated prior to the nurse giving ostomy education to a patient?

readiness to learn, as this can be a sensitive topic for some

What should be avoided when placing a wound vac?

allowing the foam piece to touch the intact skin

What type of wounds are Penrose drains common in?

animal bites

What type of drain may be expected with a mastectomy?

JP drain

Rapid breaths followed by period of apnea may be seen in what conditions, what is this pattern called?

brain insult (Stroke, MI, brain infection/encephalopathy), Biots Respirations

Exam 2 Flashcards

(83 cards)